Comment

The challenges in moving closer to place-based commissioning

Dr Graham Jackson, chair of NHS Aylesbury Vale CCG and the new co-chair of NHS Clinical Commissioners (NHSCC), discusses the challenges facing commissioners.

There is no doubt in my mind that taking on the role of co-chair of NHSCC at this time will be challenging. Not only to follow on from the excellent work Steve Kell has done but I will partner with the very experienced Amanda Doyle, who now adds Sustainability and Transformation Plans (STPs) leader to her portfolio. I take up the role at a particularly interesting and challenging time for CCGs. I am a passionate believer that clinical leadership embedded within the management structure of the NHS must be supported and maintained. 

CCGs have demonstrated over the past three years a great ability to innovate and develop services, cognisant of a local population’s needs. They have managed this in many areas at a time of increasing fiscal restraint. Locally focused clinical commissioning really supports the needs of the population, but risks systems being isolated and too introspective. NHSCC as a member organisation supports these CCGs, provides guidance and shares best practice, in addition to its role as the collective voice of CCGs. 

The NHSCC board is wholly elected and, therefore, can be truly representative of constituent CCGs each board member covers. 

Focus on the long-term view 

CCGs need to continue to focus on the long-term view; clinicians know full well that for significant population health enhancement 12-month plans are just not good enough. We need to work more closely with our local authorities and public health activities need to be bolted onto the strategic plans around Long Term Conditions (LTCs) management. Effective healthy living support in earlier life will delay (or even abort) the onset of many LTCs. CCGs have now been given three-year budget allocations and that is a start when trying to invest in services that may take some time to demonstrate the full benefit. But the NHS is still measured on a 12-month fiscal cycle, for reasons we all understand; however it is very difficult, maybe impossible, to significantly invest to transform and reap the reward in one fiscal cycle. 

Clinical leadership is key in my mind, but at a time when we need to build or at least maintain these clinical leaders, we have an ever increasing workforce challenge. There are many examples of experienced commissioning leaders returning to full clinical practice. NHSCC needs to support others in the system to nurture new talent and support the leaders for tomorrow. Those leaders should come from many different professions to reflect the multi-disciplinary approach of the modern NHS. 

Moving to place-based commissioning 

However, the job for now is to move closer to place-based commissioning, getting the equilibrium right between the focus on the needs of the local populations, and balancing that against the necessity of working at scale when it is prudent and correct to do so. 

Much has been said (and will be said) about the wisdom behind STP footprints. However, undoubtedly, there are commissioning and provision decisions that make sense to make at scale. Our responsibility is to make sure that localities are not isolated by the bigger picture and CCGs are well placed to defend the ‘sovereignty’ and needs of the local communities they serve. 

The money! Can’t we just stop talking about whose deficit it is? It’s everyone’s! Commissioner, acute trust, community provider, whoever: the money belongs to the people, and we have a joint responsibility to use it wisely. New models of care will see blurring of the boundaries between constituent parts of the NHS; we will have to become more collective. 

Stringent lines of governance 

Blurring of boundaries will need to lead to more stringent lines of governance; conflicts of interest will always be there with the trip wire; we need to be aware and transparently manage this challenge. So far, many CCGs have taken on primary care commissioning with varying levels of activity, but NHSCC has done much work with other partners to support this and continues to work closely with NHS England to complete this transition. 

I am looking forward to working even more closely with the excellent NHSCC team, led by Julie Wood, and am honoured to be able to take on the position of co-chair of the board of such a high-quality group of NHS leaders.

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